A critical threshold for global pediatric surgical workforce density.

PURPOSE: 1.7 billion children lack access to surgical care, particularly in low- and middle-income countries (LMIC). The pediatric surgical workforce density (PSWD), an indicator of surgical access, correlates with survival of complex pediatric surgical problems. To determine if PSWD also correlates with population-level health outcomes for children, we compared PSWD with pediatric-specific mortality rates and determined the PSWD associated with improved survival. METHODS: Using medical licensing registries, pediatric surgeons practicing in 26 countries between 2015 and 2019 were identified. Countries' PSWD was calculated as the ratio of pediatric surgeons per 100,000 children. The correlation between neonatal, infant and under 5 mortality rates and PSWD was assessed using Spearman's correlations and piecewise linear regression models. RESULTS: Four LIC, eight L-MIC, ten UMIC and four HIC countries, containing 420 million children, were analyzed. The median PSWD by income group was 0.03 (LIC), 0.12 (L-MIC), 1.34 (UMIC) and 2.13 (HIC). PSWD strongly correlated with neonatal (0.78, p < 0.001), infant (0.82, p < 0.001) and under 5 (0.83, p < 0.001) mortality rates. Survival improved with increasing PSWD to a threshold of 0.37. CONCLUSION: PSWD correlates with pediatric population mortality rates, with significant improvements in survival with PSWD > 0.37. Currently, PSWD in LMICs is inadequate to meet UN Sustainable Development Goal 3.2 for child mortality.

Expansion of national surgical, obstetric, and anaesthesia plans in Latin America: can Brazil be next?

On the sidelines of the 75th Session of the Regional Committee of the World Health Organization for the Americas, the Republic of Ecuador hosted an event to expand on National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs). NSOAPs are policy frameworks that offer governments a pathway to incorporate surgical planning into their overall health strategies. In Latin America, Ecuador became the first country to lead the development of an NSOAP and is fostering regional efforts for other Latin American countries to have sustainable surgical strengthening plans. Brazil is a prominent candidate for enrolling in an NSOAP process to enhance its public health system's functionality. An NSOAP in Brazil can help mitigate social disparities, promote greater efficiency in allocating existing resources, and optimise public health system financing. This process can also encourage the creation of resources and distinct NSOAP vocabulary in Portuguese to facilitate the development of NSOAPs in other Portuguese-speaking and low- and middle-income countries. In this viewpoint, we explore why an NSOAP can benefit Brazil's surgical system, national features that enable surgical policymaking, and how multiple stakeholder engagement can contribute to the country's planning, validation, and implementation of an NSOAP.

The current status of surgical care in the Asia-Pacific region and opportunities for improvement: proceedings.

The World Health Assembly resolution 68.15 recognised emergency and essential surgery as a critical component of universal health coverage. The first session of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on the current status of surgical care and opportunities for improvement. During this session, Ministries of Health and World Health Organization (WHO) Regional Directors shared country- and regional-level progress in surgical system strengthening. The WHO Western Pacific Regional Office (WPRO) has developed an Action Framework for Safe and Affordable Surgery, whilst the WHO South-East Asia Regional Office (SEARO) highlighted their efforts in emergency obstetric care, workforce strengthening, and blood safety. Numerous countries have begun developing and implementing National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs). Participants agreed surgical system strengthening is an integral component of universal health coverage, pandemic preparedness, and overall health system resilience. Participants discussed common challenges, such as the COVID-19 pandemic, climate change, workforce capacity building, and improving access for hard-to-reach populations. They generated and shared common solutions, including strengthening surgical care capacity in first-level hospitals, anaesthesia task-shifting, remote training, and integrating surgical care with public health, preventive care, and emergency preparedness. Moving forward, participants committed to developing and implementing NSOAPs and agreed on the need to raise political awareness, build a broad-based movement, and form intersectoral collaborations.

Financing surgical, obstetric, anaesthesia, and trauma care in the Asia-Pacific region: proceedings.

Surgical, obstetric, and anaesthesia care saves lives, prevents disability, promotes economic prosperity, and is a fundamental human right. Session two of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region discussed financing strategies for surgical care. During this session, participants made a robust case for investing in surgical care given its cost-effectiveness, macroeconomic benefits, and contribution to health security and pandemic preparedness. Funding for surgical system strengthening could arise from both domestic and international sources. Numerous strategies are available for mobilising funding for surgical care, including conducive macroeconomic growth, reprioritisation of health within government budgets, sector-specific domestic revenue, international financing, improving the effectiveness and efficiency of health budgets, and innovative financing. A wide range of funders recognised the importance of investing in surgical care and shared their currently funded projects in surgical, obstetric, anaesthesia, and trauma care as well as their funding priorities. Advocacy efforts to mobilise funding for surgical care to align with the existing funder priorities, such as primary health care, maternal and child health, health security, and the COVID-19 pandemic. Although the COVID-19 pandemic has constricted the fiscal space for surgical care, it has also brought unprecedented attention to health. Short-term investment in critical care, medical oxygen, and infection prevention and control as a part of the COVID-19 response must be leveraged to generate sustained strengthening of surgical systems beyond the pandemic.

Strategic planning to improve surgical, obstetric, anaesthesia, and trauma care in the Asia-Pacific region: introduction.

Surgical, obstetric, and anaesthesia care are required to treat one-third of the global disease burden. They have been recognised as an integral component of universal health coverage. However, five billion people lack access to safe and affordable surgical care when required. Countries in the Asia-Pacific region are currently developing strategies to strengthen their surgical care systems. The Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region meeting is a three-part virtual meeting series that brought together Ministries of Health, intergovernmental organisers, funders, professional associations, academic institutions, and nongovernmental organisations in the Asia-Pacific region. The meeting series took place over three virtual sessions in February and March 2021. Each session featured framing talks, panel presentations, and open discussions. Participants shared lessons about the challenges and solutions in surgical system strengthening, discussed funding opportunities, and forged strategic partnerships. Participants discussed strategies to build ongoing political momentum and mobilise funding, the implications of the COVID-19 pandemic and climate change on surgical care, the need to build a broad-based, inclusive movement, and leveraging remote technologies for workforce development and service delivery. This virtual meeting series is only the beginning of an ongoing community for knowledge sharing and strategic collaboration towards surgical system strengthening in the Asia-Pacific region.

Strategic partnerships to improve surgical care in the Asia-Pacific region: proceedings.

Emergency and essential surgery is a critical component of universal health coverage. Session three of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on strategic partnerships. During this session, a range of partner organisations, including intergovernmental organisations, professional associations, academic and research institutions, non-governmental organisations, and the private sector provided an update on their work in surgical system strengthening in the Asia-Pacific region. Partner organisations could provide technical and implementation support for National Surgical, Obstetric, and Anaesthesia Planning (NSOAP) in a number of areas, including workforce strengthening, capacity building, guideline development, monitoring and evaluation, and service delivery. Participants emphasised the importance of several forms of strategic collaboration: 1) collaboration across the spectrum of care between emergency, critical, and surgical care, which share many common underlying health system requirements; 2) interprofessional collaboration between surgery, obstetrics, anaesthesia, diagnostics, nursing, midwifery among other professions; 3) regional collaboration, particularly between Pacific Island Countries, and 4) South-South collaboration between low- and middle-income countries (LMICs) in mutual knowledge sharing. Partnerships between high-income countries (HIC) and LMIC organisations must include LMIC participants at a governance level for shared decision-making. Areas for joint action that emerged in the discussion included coordinated advocacy efforts to generate political view, developing common monitoring and evaluation frameworks, and utilising remote technology for workforce development and service delivery.

Assessment of essential surgical and anaesthesia care capacity: a cross-sectional study in five Pacific Island Countries.

Background: Pacific Island Countries (PICs) face unique challenges in providing surgical care. We assessed the surgical care capacity of five PICs to inform the development of National Surgical, Obstetric and Anaesthesia Plans (NSOAP). Methods: We conducted a cross-sectional survey of 26 facilities in Fiji, Tonga, Vanuatu, Cook Islands, and Palau using the World Health Organization - Program in Global Surgery and Social Change Surgical Assessment Tool. Findings: Eight referral and 18 first-level hospitals containing 39 functioning operating theatres, 41 post-anaesthesia care beds, and 44 intensive care unit beds served a population of 1,321,000 across the five countries. Most facilities had uninterrupted access to electricity, water, internet, and oxygen. However, CT was only available in 2/8 referral hospitals, MRI in 1/8, and timely blood transfusions in 4/8. The surgical, obstetric, and anaesthetist specialist density per 100,000 people was the highest in Palau (49.7), followed by Cook Islands (22.9), Tonga (9.9), Fiji (7.1), and Vanuatu (5.0). There were four radiologists and 3.5 pathologists across the five countries. Surgical volume per 100,000 people was the lowest in Vanuatu (860), followed by Fiji (2,247), Tonga (2,864), Cook Islands (6,747), and Palau (8,606). The in-hospital peri-operative mortality rate (POMR) was prospectively monitored in Tonga and Cook Islands but retrospectively measured in other countries. POMR was below 1% in all five countries. Interpretation: Whilst PICs share common challenges in providing specialised tertiary services, there is substantial diversity between the countries. Strategies to strengthen surgical systems should incorporate both local contextualisation within each PIC and regional collaboration between PICs. Funding: None.

A granular analysis of service delivery for surgical system strengthening: Application of the Lancet indicators for policy development in Colombia.

Background: The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution. Methods: Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location. Findings: In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement. Interpretation: This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan. Funding: None.

Development of a surgical assessment tool for national policy monitoring & evaluation in Ethiopia: A quality improvement study.

BACKGROUND: A baseline assessment of surgical capacity is recommended as a first-step to surgical system strengthening in order to inform national policy. In Ethiopia, the World Health Organization's Tool for Situational Analysis (WHO SAT) was adapted to assess surgical, obstetric, and anesthesia capacity as part of a national initiative: Saving Lives Through Safe Surgery (SaLTS). This study describes the process of adapting this tool and initial results. MATERIALS AND METHODS: The new tool was used to evaluate fourteen hospitals in the Southern Nations, Nationalities, and People's Region of Ethiopia between February and March 2017. Two analytic methods were employed. To compare this data to international metrics, the WHO Service Availability and Readiness Assessment (SARA) framework was used. To assess congruence with national policy, data was evaluated against Ethiopian SaLTS targets. RESULTS: Facilities had on average 62% of SARA items necessary for both basic surgery and comprehensive surgery. Primary, general, and specialized facilities offered on average 84%, 100%, and 100% of SARA basic surgeries, and 58%, 73% and 90% of SARA comprehensive surgeries, respectively. An average of 68% of SaLTS primary surgeries were available at primary facilities, 83% at general facilities, and 100% at specialized facilities. General and specialized hospitals offered an average of 80% of SaLTS general surgeries, while one specialized hospital offered 38% of SaLTS specialized surgeries. CONCLUSION: While the modified SaLTS Tool provided evaluation against Ethiopian national benchmarks, the resultant assessment was much lengthier than standard international tools. Analysis of results using the SARA framework allowed for comparison to global standards and provided insight into essential parts of the tool. An assessment tool for national surgical policy should maintain internationally comparable metrics and incorporation into existing surveys when possible, while including country-specific targets.

Identifying essential components of surgical care delivery through quality improvement: An updated surgical assessment tool.

BACKGROUND: Surgical care is a cost-effective intervention with major public health impact. Yet, five billion people do not have access to surgical and anesthesia care. This overwhelming unmet need has generated a rising interest in scale-up of these services globally. The purpose of this research was to aggregate available guidelines and create a synthesized tool that could provide valuable information at the local, national, and international health system levels. METHODS: A systematic review identified current documents cataloging elements for surgical care provision. Items with a reported frequency of >30% were included in the initial draft of the Surgical Assessment Tool. This underwent two cycles of Delphi-method expert opinion elicitation from providers working in low- and middle-income settings. Finally, the tool underwent vetting by the World Health Organization to create an expert-endorsed survey. RESULTS: Fifteen surgical tools were identified, containing a total of 216 unique elements in the following domains: infrastructure (n = 152), service delivery (n = 49), and workforce (n = 15). The final tool consisted of 169 items in the following domains: infrastructure (n = 35), service delivery (n = 92), workforce (n = 20), information management (n = 10), and financing (n = 12). CONCLUSION: Informed planning is critical to ensure successful expansion of surgical services. Our analysis of current tools shows varying agreement on the essential components of surgical care delivery. This updated tool serves as a crucial method to systematically assess surgical systems as well as monitor, modify, and strengthen in a scalable fashion. Importantly, it has the potential to be used in all settings after adaptation to local context.